Neoadjuvant chemoimmunotherapy in non-small cell lung cancer: evolving resectability criteria, biomarker-driven postoperative management, and emerging therapeutic strategies

Neoadjuvant chemoimmunotherapy (chemo-IO) has fundamentally reshaped the treatment paradigm for resectable non-small cell lung cancer (NSCLC), challenging long-held surgical boundaries and redefining what constitutes "resectable" disease. Trials such as CheckMate-816, KEYNOTE-671, and AEGEAN have demonstrated that integrating immune checkpoint blockade with chemotherapy yields unprecedented rates of pathological response and event-free survival, positioning chemo-IO as the new global standard for stage IB-IIIA NSCLC. Yet these advances bring new complexities; how do we define resectability in an era of immunotherapeutic downstaging, and how should multidisciplinary teams adapt to evolving biology? Traditional radiological and anatomic criteria now sit alongside immune-mediated regression and circulating tumor DNA (ctDNA) kinetics as measures of treatment success. ctDNA clearance and pathological response serve as powerful surrogates for long-term survival, with ongoing studies such as MERMAID-1/2 exploring their potential to guide adjuvant therapy and spare overtreatment. The modern challenge lies in integrating these biomarkers into surgical decision-making and developing standardized, biology-informed resectability frameworks. Future progress will depend on close collaboration between surgeons, oncologists, and translational scientists to expand surgical candidacy safely and define the next generation of curative strategies in lung cancer.